<div id="postResults"></div>
{clni_form}
<input type="submit" value="Update" />
<div style="clear: both;"></div>
<br />
<table>
<tr>
<td>
<b>Smoker</b>:<br />
{input type="radio" name="social_history_smoker" value="current" options="Current" display="horizontal"}
{input type="radio" name="social_history_smoker" value="past" options="Past" display="horizontal"}
{input type="radio" name="social_history_smoker" value="never" options="Never" display="horizontal"}
<br />
<b>Alcohol Use</b>:<br />
{input type="radio" name="social_history_alcohol_use" value="none" options="None" display="horizontal"}
{input type="radio" name="social_history_alcohol_use" value="occasionally" options="Occasionally" display="horizontal"}
{input type="radio" name="social_history_alcohol_use" value="frequently" options="Frequently" display="horizontal"}
<br />
<b>Drug Use Use</b>:<br />
{input type="radio" name="social_history_drug_use" value="yes" options="Yes" display="horizontal"}
{input type="radio" name="social_history_drug_use" value="no" options="No" display="horizontal"}
</td>
<td>&nbsp&nbsp;</td>
<td valign="top"><b>Comments</b>:<br />{input type="text" rows="15" cols="80" name="social_history_comments"}</td>
</tr>
</table>
</form>
